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As rheumatology fellows approach the end of what for many is 25th grade, it’s time to focus on what you want to do for the rest of your life. For most rheumatology fellows it will be some form of clinical practice, although enormous opportunities exist throughout the medical field for you to apply your talents. Some of you will find remaining in academia holds allure, and others will focus on finding a position in government, industry or technology.
Clinical Practice Option
In this article I lay out the clinical practice option: how to find and assess a position. I also review the fundamentals of applying for a job, including tips on the interview, and some essentials of evaluating a contract.
The majority of fellows will enter the workforce with debt—debt that has been incurred with the promise of earning a reasonable income as a fully hatched professional leaving the training eggshell.1 Paying off that debt typically coincides with other economic pressures that may influence your quest for gainful and career-long employment, including buying a home and, for many, meeting the needs of a growing family, saving for your children’s education and, finally, starting the lifelong process of saving for your eventual retirement. Thus, economics may play a role in how you assess employment opportunities and job selection.
Let me be clear: Private practice, contrary to many recent reports of its demise, is thriving, and rheumatology private practice is viable. To illustrate, the most recent ACR Workforce Study of Rheumatology Specialists in the U.S. indicated that by 2025 almost 7,500 full-time rheumatologists will be needed nationwide, but after accounting for retiring and part-time rheumatologists, the U.S. will have only 3,645 practitioners.2 What does that mean for you? Simply, the workforce has a place for you, and you will be very busy.
Despite this very high demand, rheumatologists’ mean income, according to reports published annually in Medscape, is low relative to other medical and surgical subspecialties.3 This is due to a bending of the supply and demand curve caused by low reimbursements for cognitive services and the ability of large insurers, insensitive to the costs of conducting a practice, to dictate payment terms to providers.
Nonetheless, rheumatologists do have the ability to push back and improve payment terms with private insurers, and many have done so successfully. This is a topic I hope to explore in a subsequent article. Suffice it to say that many larger groups and some smaller entities in regions of the U.S. with very few rheumatologists have found economic success that significantly exceeds the Medscape income data.
Setting Considerations
Let’s assume that your plan is to work in a pure clinical setting. What are your options?
- Hospital or health system employment;
- Solo practice;
- Multispecialty group practice; or
- Single-specialty group practice.
Your options may be influenced by where you plan to work. In some regions areas, clinical rheumatology positions are locked up by large hospital systems that have purchased local practices or recruited physician employees. If you want to be in such an area, your only option—other than opening your own practice—is to apply to that system.
Hospital Systems
Many organizations have detailed the growing percentage of the physician workforce employed by hospital systems and private equity firms.4 This trend is stronger in some parts of the country and in some specialties more than others, and won’t necessarily continue. Surveys have shown that using institutional valuation methodologies, hospitals may lose money on rheumatologists by not crediting them with downstream revenues (e.g., income derived from laboratory tests, imaging studies, infusions and surgical referrals).
The Medscape 2018 physician compensation report showed that self-employed physicians—although not specifically rheumatologists—may earn as much as 50% more on average than those who are employed.
As Medicare attempts to gain control over costs, the traditional site-of-service revenue differential that hospitals receive for outpatient services provided by acquired specialists, relative to independent entities, may disappear.5 Should this occur, I believe we may see some acquired practices cut loose from the systems that purchased them. Additionally, the rate of hiring has been slowing over the past few years, and many have questioned whether hospital acquisitions of outpatient medical practices will be sustainable.
Further, the impact of the pandemic on practice acquisition trends is unclear.
Private Practice
If private practice is your preference and the region you want to work in is not locked up, then your choices will be between solo practice or single- and multispecialty groups. The groups you investigate for employment can be further divided into smaller and larger entities.
Solo Practice
Few physicians entering practice today choose to open up their own solo practice. Going solo has lots of barriers, both economic and regulatory. If solo practice is what you want, a Google search will provide you with a considerable amount of literature that can offer a map to help get you started. The American Medical Association, the American College of Physicians and others have resources that may be helpful.
Solo practice has its pros and cons. The major advantage is that you have complete autonomy. Unfortunately, being solo means you carry all the risks, pay all the office expenses (e.g., rent, staff salaries, insurance) and must figure out what to do when you are out for vacation, are ill or are on maternity leave. Solo practitioners have little leverage in negotiating contracts with insurers and are vulnerable to competition. Single practitioners may find it difficult to support the infrastructure necessary to deliver and derive revenue from ancillary services.
Multispecialty Group Practice
Multispecialty group practice may provide a rheumatologist with an in-house referral source, but that may dissuade physicians not in the group from referring patients to you. Income division may favor physicians in some specialties over others, typically rewarding procedural over cognitive services. Also, the attribution of income from ancillary services may not favor the rheumatologist who generates this work due to the Stark laws, which prohibit physicians from profiting financially from a self-referral.6
Group investments and purchases in some groups may serve the needs of some specialists over that of the rheumatologist—for example, the purchase of endoscopes vs. that of dual X-ray absorptiometry or ultrasound units.
Finally, coverage in a multispecialty group can be challenging for the rheumatologist covering for other members of the group and vice versa. Think about cardiologists, pulmonologists or gastroenterologists covering for you or you covering for them.
Single-Specialty Group Practice
My bias, of course, is the single-specialty group because that is the environment in which I have toiled for more than 40 years. The single-specialty group’s investments in ancillary services and staffing typically favor all of its members. Coverage of your colleagues is much more straightforward than in the multispecialty group.
It also doesn’t hurt that most surveys I have seen over the years indicate income for the rheumatologist tends to be more robust in this setting. Interestingly, the Medscape 2018 physician compensation report showed that self-employed physicians—although not specifically rheumatologists—may earn as much as 50% more on average than those who are employees.7